Medicaid Integrity Program Medicaid Integrity Contractors Deficit - - PowerPoint PPT Presentation

Medicaid Integrity Program

Medicaid Integrity Contractors

Deficit Reduction Act of 2005

• Established the Medicaid Integrity Program (MIP) in

§1936 of the Social Security Act.

• Dramatically increased Federal resources to fight

Medicaid fraud, waste, and abuse.

• Requires CMS to contract with entities to:

– Review provider claims – Audit providers and others – Identify overpayments, and – Educate providers, managed care entities, beneficiaries and

• thers with respect to payment integrity and quality of care.
• Provide effective support and assistance to States

2

Partnership with States

• Support not supplant State Medicaid program

integrity efforts.

• Work closely with States on National Audit

program.

– Target identification – Audit resolution

• Provide technical assistance and training to

State PI staff.

3

Medicaid Integrity Contractors (MICs)

• Three types of MICs:

– Audit – Review – Education

• Five jurisdictions:

– New York (CMS Regions I & II) – Atlanta (CMS Regions III & IV) – Chicago (CMS Regions V & VII) – Dallas (CMS Regions VI & VIII) – San Francisco (CMS Regions IX & X)

4

Objectives of MICs

• Ensure that paid claims were:

– For services provided and properly documented; – For services billed properly, using correct and appropriate procedure codes; – For covered services; and – Paid according to Federal and State laws, regulations, and policies.

5

Review MICs

• Analyze Medicaid claims data to identify high-

risk areas and potential vulnerabilities.

• Provide leads to the Audit MICs.
• Use data-driven approach to ensure focus on

providers with truly aberrant billing practices.

6

Audit MICs

• Conduct post-payment audits.

– Combination field and desk audits

• Fee-for-service, cost report and managed care

audits.

• Audits will identify overpayments; States will

collect overpayments and adjudicate provider appeals.

7

Education MICs

• Use findings from Audit and Review MICs to identify

areas for education.

• Work closely with Medicaid partners & stakeholders

to provide education and training.

• Will develop training materials, awareness

campaigns and conduct provider training.

• Highlight value of education in preventing Medicaid

fraud, waste, and abuse.

8

MICs

Audit MICs:

– Booz Allen Hamilton – Fox & Associates – IPRO – Health Management Systems – Health Integrity, LLC

Review MICs:

– AdvanceMed – ACS Healthcare – Thomson Reuters – IMS Govt. Solutions

Education MICs:

Information Experts Strategic Health Solutions

9

MICs by Jurisdictions

• New York (CMS Regions I & II)

– Thomson Reuters (R) and IPRO (A)

• Atlanta (CMS Regions III & IV)

– Thomson Reuters (R) and Health Integrity (A)

• Chicago (CMS Regions V & VII)

– AdvanceMed (R) and Health Integrity (A)

• Dallas (CMS Regions VI & VIII)

– AdvanceMed (R) and HMS (A)

• San Francisco (CMS Regions IX & X)

– AdvanceMed (R) and HMS (A)

R = Review MIC A = Audit MIC

10

11

Audit Process

• 1. Claims reviewed for billing aberrancies.
• 2. List of providers identified for audit vetted with

State and law enforcement.

• 3. Audit MIC performs audit.
• 4. Audit MIC prepares draft report.
• 5. Draft report is shared with the State.
• 6. Draft report sent to provider after State review.
• 7. CMS finalizes & issues final report to the State

with the identified overpayment amount.

Additional Information

http://www.cms.gov/MedicaidIntegrityProgram/ – General information/ background – Annual Reports to Congress – Comprehensive Medicaid Integrity Plan – State contacts

12

Contact Information

CMS Medicaid Integrity Group

Medicaid_Integrity_Program@cms.hhs.gov

13